Our work is part of our life and how we work is also how we live. The energy that we interact with there is what creates a happy or unhappy work environment for each of us.

I love what I do and I think that I’m pretty good at it. Those two things usually go hand in hand. But last week a particular case highlighted a few things.

The case involved a female soldier suffering from a moderate cellulitis¹. The infection was from a tooth that had had a root canal started at her base. An instrument broke off in the tooth, and infection subsequently set in.

She ended up in the emerg department at a hospital and was started on IV antibiotics and narcotics. I saw her the following day.

By the time I saw her the lip and face were still very sensitive and the overall facial swelling still existed. In a nutshell I had to basically contend with an anxious patient, attempt to achieve some discharge from a tooth that was blocked internally with the broken instrument, and also get her numbed up enough to be able to do the work.

She and I worked together to manage her anxiety and fear and so I was able to achieve some positive results with the tooth and swelling.

I was fucking exhausted afterwards. Even though the work itself for this case turned out to be fairly easy, the whole management aspect just left me feeling drained.

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Footnotes:

1. A painful swelling of the soft tissue of the mouth and face resulting from a diffuse spreading of purulent exudate along the fascial planes that separate the muscle bundles. [↩]

She: You know, eye doctors have this thing where the patient lies on their back and it rotates.

Me: Uh huh?

She: Yeah, maybe dentists should look into something like that.

Me: Uh huh?

She: It’s like the thing that mechanics use. You know, where they lie on it and then it slides under the car.

Me: Uh huh?

She: So the eye doctor rotates the patient so that they are lying upside down and the eyes fall forward and the doctor works on them from underneath.

Me: Hmm. Uh huh?

She: So wouldn’t that be easier for dentists and their patients too?

Me: Working from underneath you like you’re a car?

She: Yeah…like that…

Me: Except you’d drool all over me. No thank you.

She: Oh, you’re right. Hmm.

Me: Uh huh.

The first picture is how this premolar arrived (with the patient) to my office. Discharge was present through the gums from a chronic abscess. Looks like a radiolucent post was placed practically to the apex. There’s some remnant gutta-percha or cement mid-root and probably an apical perforation at the base of the post.

The tooth was retreated over a couple of appointments. Sure enough there was a perforation at the apex of the root, but laterally. I was never able to regain the true canal beyond the perf. A carbon fiber post was removed, Calcium Hydroxide was used as an interappointment intracanal dressing, and then MTA (Mineral Trioxide Aggregate) was used to fully obturate the canal.

There is a 21 month interval between the two films. Osseous healing is progressing well, and no mucosal lesions were evident at the time of the second film.

This case also serves as an example of the fact that a 1-year recall on endodontic cases does not provide enough time to properly evaluate healing. From a strict radiographic interpretation, this case has not healed and is therefore not currently a success. One strike against the relevance or clinical significance of that Cochrane Review.

By the way, I did address the molar’s obvious periodontal issue verbally. The patient is aware of a guarded long-term prognosis there.

Cochrane reviews are generally well-respected meta-analyses that are designed to answer important clinical questions. A Cochrane study ended the battle between OralB and Sonicare for supremacy in the electric toothbrush market. Their analysis showed that the OralB brush (at the time) was a better plaque-remover.

Single Versus Multiple Visits for Endodontic Treatment of Permanent Teeth: A Cochrane Systematic Review¹
Lara Figini, DDS, Giovanni Lodi, DDS, PhD, Fabio Gorni, MD, Massimo Gagliani, MD

The Cochrane Collaboration promotes evidence-based healthcare decision making globally through systematic reviews of the effects of healthcare intervention. The purpose of this systematic review was to investigate whether the effectiveness and frequency of short-term and long-term complications are different when endodontic procedure is completed in one or multiple visits. Randomized and quasi-randomized controlled trials enrolling patients undergoing endodontic treatment were identified by searching biomedical databases and hand-searching relevant journals. The following outcomes were considered: tooth extraction as a result of endodontic problems and radiologic failure after 1 year, postoperative discomfort, swelling, analgesic use, or sinus track. Twelve studies were included in the review. No detectable difference was found in the effectiveness of root canal treatment in terms of radiologic success between single and multiple visits. Neither single-visit root canal treatment nor multiple-visit root canal treatment can prevent 100% of short-term and long-term complications. Patients undergoing a single visit might experience a slightly higher frequency of swelling and refer significantly more analgesic use.

Before you pee on yourself out of excitement that the above study might provide some validation that single-visit root canal treatment in infected teeth offers the same therapeutic outcome as multi-visit treatment, realize a couple of things:

1. Double-blind randomized studies are rare in endodontic research, as are studies with adequate statistical power². A meta-analysis can only be as significant as the weakest study it includes.
2. Proper evaluation of endodontic healing based on radiographic changes is not appropriate after only 1 year. Strindberg³ showed this a long time ago, and so did Orstavik⁴ more recently.

Footnotes:

1. Figini L, Lodi G, Gorni F, Gagliani M. Single versus multiple visits for endodontic treatment of permanent teeth. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD005296. [↩]
2. Trope M, Delano EO, Orstavik D. Endodontic treatment of teeth with apical periodontitis: single vs. multivisit treatment. J Endod. 1999 May;25(5):345-50. [↩]
3. Strindberg LZ (1956). The dependence of the results of pulp therapy on certain factors. An analytic study based on radiographic and clinical follow-up examinations. Acta Odontol Scand 14(Suppl 21):1–175. [↩]
4. Orstavik D. Time-course and risk analyses of the development and healing of chronic apical periodontitis in man. Int Endod J. 1996 May;29(3):150-5. [↩]

Everyone likes to show off their best work, but when can you remember being at a continuing education presentation and the presenter shows off work that they have produced that is less than ideal?

Here is a case that was fraught with issues from the beginning:

The patient will be on a recall schedule with me for the next year or two while I keep tabs on healing within the jaw bone. Hopefully the problem of chronic infection from this tooth is solved. Options are very limited now if the infection persists.